help with ethical issues

Nurses General Nursing

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i have a senario and if anyone could help me i'd be glad to hear from you!!!!

  • Mrs Smith believed that she wanted everything to be done to keep her alive and her children supported this. When she developed advanced dementia from multiple strokes she became unable to walk, talk or feed due to diminished swallowing. She was being nourished through a percutaneous gastric feeding tube (PEG) which she had pulled out numerous times which was then replaced by a nasogratric tube which she had also pulled out on many occasions.

The family felt compelled to respect their mother's wishes for treatment to keep her alive and requested that the nursing staff restrain their mother by tying her hands so that she couldn't pull out the PEG/nasogastric tube. The restraints caused Mrs Smith great emotional distress but without them she would not get enough nutrition. The nurses felt that restraint violated their obligation to threat their patient with respect and dignity.

Outline the ethical issues in this scenario from both the patient's and the nurses' perspectives.

thanks :-)

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So far, what are your thoughts? What are your ethical values in this situation? What are the conflicts you see between your values and those of the family, by extension of patient' values?

We enjoy helping with homework but I think you will find most of the nurses want to see how far you can think the questions through. Once we see these questions answered we will be in a better situation to assist you.

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Specializes in ICU.

Once a person has advanced dementia, only their previous wishes can be honored. Someone with advanced dementia can't make decisions for themselves. And as for honoring any of their wishes, that falls to the family who now is making the decisions. If they say she dies, she dies. If they say she lives, she lives. There is no right or wrong to it. There is no ethical issue. To not restrain the patient would be involuntary passive euthanasia--and there is no right or wrong to that either. It's all up to the family member who is leagally empowered to decide.

My job as a nurse is to care for the patient in front of me. If a family member wants my advice, I will tell them the complete truth of the situation and what I have experienced in similar situations. If they want my personal opinion, I will give that to them as well, so long as they realize it is just my personal opinion. If they see me as a good person, they will take my personal opinion to heart. If they don't see me that way, they won't.

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Specializes in ICU/CCU, Home Health/Hospice, Cath Lab,.
Once a person has advanced dementia, only their previous wishes can be honored. Someone with advanced dementia can't make decisions for themselves. And as for honoring any of their wishes, that falls to the family who now is making the decisions. If they say she dies, she dies. If they say she lives, she lives. There is no right or wrong to it. There is no ethical issue. To not restrain the patient would be involuntary passive euthanasia--and there is no right or wrong to that either. It's all up to the family member who is leagally empowered to decide.

My job as a nurse is to care for the patient in front of me. If a family member wants my advice, I will tell them the complete truth of the situation and what I have experienced in similar situations. If they want my personal opinion, I will give that to them as well, so long as they realize it is just my personal opinion. If they see me as a good person, they will take my personal opinion to heart. If they don't see me that way, they won't.

I'm afraid I have to disagree here. This is clearly an ethical issue, as how we treat this woman and how we feel about how we treat her is tied into our sense of right and wrong which is clearly an ethical concern. You might argue for a sense of right and wrong based on legality but that is still a level of morality.

Because people view morality differently, whatever the family decides will be viewed as right or wrong based on our own ethics.

Now since someone with advanced dementia can not decide for themselves what is the correct thing to do in regards to care, it falls to family or power of attorney to decide. They can go by prior stated wishes or they can decide that the patient might not have really considered all the possible outcomes of her decision and that she would never have wished this type of life if she saw herself now. We as nurse can decide on the ethics of this situation either based on legality (family can legally decide hence their decision is right) or based on personal morality (which could go either way - 1 RN might believe all life is sacred and she be lived until the end, another might decide that quality of life is a higher priority). As for the patient there is no ethical concern as she lacks the ability to decide between right and wrong - she can't make an ethical choice.

Hope this helps

Pat

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Specializes in ICU.
I'm afraid I have to disagree here. This is clearly an ethical issue, as how we treat this woman and how we feel about how we treat her is tied into our sense of right and wrong which is clearly an ethical concern. You might argue for a sense of right and wrong based on legality but that is still a level of morality.

Good point. :up:

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Specializes in medicine and psychiatry.

I'm going to have to hang with Flightline on this one. It may be an ethical issue but it is not mine.

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thanks for getting me started :-) much appreciated

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I'm afraid I have to disagree here. This is clearly an ethical issue, as how we treat this woman and how we feel about how we treat her is tied into our sense of right and wrong which is clearly an ethical concern. You might argue for a sense of right and wrong based on legality but that is still a level of morality.

Because people view morality differently, whatever the family decides will be viewed as right or wrong based on our own ethics.

Now since someone with advanced dementia can not decide for themselves what is the correct thing to do in regards to care, it falls to family or power of attorney to decide. They can go by prior stated wishes or they can decide that the patient might not have really considered all the possible outcomes of her decision and that she would never have wished this type of life if she saw herself now. We as nurse can decide on the ethics of this situation either based on legality (family can legally decide hence their decision is right) or based on personal morality (which could go either way - 1 RN might believe all life is sacred and she be lived until the end, another might decide that quality of life is a higher priority). As for the patient there is no ethical concern as she lacks the ability to decide between right and wrong - she can't make an ethical choice.

Hope this helps

Pat

I wonder if the patient is making a choice, even in her diminished capacity. She is the only one who knows just what it is to live in her body right now. One of my first patients was a 90 y.o. woman with dementia who stopped eating and had pulled out 3 ivs and 2 foleys, very active and wiry she was - no way was she going to tolerate an NGT or PEG; restraint would have been cruelty - and the family was going to let her go.

Insofar as a demented or brain-damaged patient can demonstrate by actions or statements what her present will is now that she is actually experiencing a diminished state, that should be taken into account, imo.

You could have your hypothetical lady trying to refuse sustenance and all attachments or another one who had said "no tubes" appearing quite content with her new life.

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witnessed a very old, woman with dementia who kept pulling out her tube. She could only communicate :up::down: for yea-no questions. The MS finally sat down with her and told her would die if she did not keep the tube in. Did she want that? Immediately :up:.

We left the tube out, changed to Comfort Care. She passed away in a few days. For many people with dementia there is more going on in the brain than we give credit. When communication is lost, many believe intelligence is gone. There are many ways to communicate.

That is one ethical consideration I have. Is there a way to communicate that we are not using in this case? The strokes probably did not knock out all her frontal cortex.

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